System and method for auditing insurance vendors

Abstract

A computerized system and computer-implemented method for enabling insurance vendor self-audits that receives referral data from a vendor, samples the referrals, assigns audit questions to each referral within the sample of referrals, presents the audit questions to the vendor and receives answers from the vendor, scores the answers based on rules, and reports the audit scores.

What is claimed is: 
     
       1. A method implemented in one or more computer processors for enabling an insurance company to audit third-party vendors who provide services to an insured in connection with an insurance claim, comprising:
 storing by the one or more processors a plurality of vendor referrals associated with a third-party vendor in a database implemented in a data storage device, wherein each of the vendor referrals identifies an insured service that has been provided by the third-party vendor to an insured and billed to the insurance company; 
 storing by the one or more processors a plurality of audit questions in the database implemented in the data storage device; 
 selecting by the one or more processors a set of audit questions from the plurality of audit questions stored in the database based on the types of insured services identified in the plurality of vendor referrals associated with the third-party vendor stored in the database; and 
 assessing by the one or more processors the performance of the insured services by the third-party vendor relative to a set of standards predetermined by the insurance company based on answers to the selected set of audit questions. 
 
     
     
       2. The method as claimed in  claim 1 , further comprising receiving, at a communications hub, the plurality of vendor referrals. 
     
     
       3. The method as claimed in  claim 2 , wherein the plurality of vendor referrals associated with the third-party vendor are uploaded by the third-party vendor via the communications hub. 
     
     
       4. The method as claimed in  claim 1 , further comprising transmitting at least the selected set of audit questions to a client machine associated with the third-party vendor. 
     
     
       5. The method as claimed in  claim 4 , further comprising receiving answers to the selected set of audit questions at the one or more computer processors. 
     
     
       6. The method as claimed in  claim 1 , further comprising generating by the one or more computer processors a scorecard based on the answers to the selected set of audit questions, which indicates how the third-party vendor has performed relative to the set of predetermined standards. 
     
     
       7. The method as claimed in  claim 6 , further comprising transmitting the scorecard by the one or more computer processors to a client machine associated with the third-party vendor. 
     
     
       8. The method as claimed in  claim 6 , further comprising generating by the one or more computer processors a vendor workflow schedule in the database based on the scorecard. 
     
     
       9. The method as claimed in  claim 6 , wherein the selected set of audit questions is selected based on a previous scorecard associated with the third-party vendor. 
     
     
       10. The method as claimed in  claim 6 , further comprising storing by the one or more computer processors the scorecard in the database. 
     
     
       11. The method as claimed in  claim 1 , further comprising randomly selecting by the one or more computer processors a subset of vendor referrals from the plurality of vendor referrals associated with the third-party vendor stored in the database; and
 wherein the set of audit questions is selected from the plurality of audit questions stored in the database based on the types of insured services identified in the selected subset of vendor referrals. 
 
     
     
       12. A system for enabling an insurance company to audit third-party vendors who provide services to an insured in connection with an insurance claim, comprising:
 at least one data storage device implementing a database configured to store a plurality of audit questions and a plurality of vendor referrals associated with a third-party vendor; 
 wherein each of the plurality of vendor referrals associated with the third-party vendor identifies an insured service that has been provided by the third-party vendor to an insured and billed to the insurance company; and 
 at least one computer processor configured to:
 select a set of audit questions from the plurality of audit questions stored in the database based on the types of insured services identified in the plurality of vendor referrals associated with the third-party vendor stored in the database; and 
 assess the performance of the insured services by the third-party vendor relative to a set of standards predetermined by the insurance company based on the answers to the selected set of audit questions. 
 
 
     
     
       13. The system as claimed in  claim 12 , wherein the at least one computer processor is further configured to receive the plurality of vendor referrals associated with the third-party vendor, which are uploaded to the system by the third-party vendor. 
     
     
       14. The system as claimed in  claim 13 , wherein the at least one computer processor is further configured to validate each of the plurality of vendor referrals for sufficient information, and to identify at least those vendor referrals that fail validation. 
     
     
       15. The system as claimed in  claim 12 , wherein at least some of the plurality of vendor referrals are related to worker compensation claims and include information related to services associated with medical treatment of the insured. 
     
     
       16. The system as claimed in  claim 12 , wherein the at least one computer processor is further configured to retrieve, edit, and store the plurality of audit questions in the database. 
     
     
       17. The system as claimed in  claim 12 , wherein the at least one computer processor is further configured to transmit at least the selected set of audit questions to a client machine associated with the third-party vendor. 
     
     
       18. The system as claimed in  claim 17 , wherein the at least one computer processor is further configured to receive answers to the selected set of audit questions at the one or more computer processors. 
     
     
       19. The system as claimed in  claim 12 , wherein the at least one computer processor is further configured to generate a scorecard based on the answers to the selected set of audit questions, the scorecard indicating how the third-party vendor has performed relative to set of predetermined standards. 
     
     
       20. The system as claimed in  claim 19 , wherein the at least one computer processor is further configured to transmit the scorecard to a client machine associated with the third-party vendor. 
     
     
       21. The system as claimed in  claim 19 , wherein the at least one computer processor is further configured to generate a vendor workflow schedule in the database based on the scorecard. 
     
     
       22. The system as claimed in  claim 19 , wherein the at least one computer processor is further configured to select the set of audit questions from the database based on a stored scorecard associated with the third-party vendor. 
     
     
       23. The system as claimed in  claim 19 , wherein the at least one computer processor is further configured to store the scorecard in the database. 
     
     
       24. The system as claimed in  claim 23 , wherein the at least one computer processor is further configured to assess stored scorecards to determine one or more vendor performance trends. 
     
     
       25. The system as claimed in  claim 24 , wherein the at least one computer processor is further configured to generate a recurring deficiencies checklist based on the vendor performance trends. 
     
     
       26. The system as claimed in  claim 12 ,
 wherein the at least one computer processor is further configured to randomly select a subset of vendor referrals from the plurality of vendor referrals associated with the third-party vendor stored in the database; and 
 wherein the set of audit questions is selected from the plurality of audit questions stored in the database based on the types of insured services identified in the selected subset of vendor referrals.